Medicine isn't an exact science, the human body is much too complicated for that.
Doctors train for years to learn how to take a list of symptoms and try to figure out what ails someone, but they are limited by their own experiences.
Unfortunately, this means mistakes are sometimes made, and those mistakes can greatly impact a patient's life.
Reddit user u/big-juicy724 asked:
Bit of a weird one, because the request for a second opinion came from an intensivist and I was a contributor to their treatment plan.
I work in poisons control. Had a call from a green, but very astute young doctor with a middle-aged female patient presenting with a vague 36-48hr history of malaise, confusion, hypoxia from hyperventilation, and hallucinations. On workup was noted to have pulmonary edema (lung fluid buildup), metabolic acidosis, acute kidney injury, sinus tachy and raised CRP & WCC, suggestive of infection but no temperature. The initial diagnosis was sepsis.
This keen-eyed doctor, pretty fresh out of med school, decided to do a salicylate level on this lady because the hyperventilation paired with metabolic acidosis and AKI was enough to prompt her suspicions of aspirin poisoning, even though they could just as easily be explained by sepsis as well.
The level came back high. Not huge, but high, which prompted her to phone me for a second opinion on how relevant the finding was in terms of the patient's clinical picture. Simultaneously, the patient's family investigated the property and located numerous aspirin blister packs suggesting she had been dosing herself for chronic pain, which was present in the medical history.
Chronic salicylate poisoning is insidious and has been referred to as a "pseudosepsis" in the medical literature as it often causes similar features.
Comparing a high level in chronic poisoning to the same level in acute poisoning, features are much more severe in chronic poisoning (i.e. pulmonary edema, hypoxia, AKI etc) - there is a disparity. We recommended certain treatments (all hail sodium bicarbonate) and the patient made a full recovery after a 2 week hospital stay.
Whilst there was no question an infective cause was present and contributory, I was impressed with the green doctor's intuition and willingness to consider other causes - I feel like it greatly improved the patient's treatment.
Here's a cautionary tale why urgent cares should NEVER treat eye issues.
Lady was referred to me after 2 weeks of treated for a red painful eye. The PA and MDs that saw her tried allergy meds and anti biotic is thinking it was allergic or bacterial conjunctivitis, or hoping it was mild viral that would resolve on its own.
So I took one look at her and knew it was a herpes simplex infection in her cornea. She was in pain and had been mistreated for 2 weeks. Got her on anti virals, but after discussing how it was odd she didn't have any active herpetic sores, but had a really bad cough that the ER said was just pneumonia and would go away with antibiotics.
I told her to get it checked with a pulmonologist because it didn't sound like pneumonia and it wasn't getting better. I saw her 3 months later to monitor her corneal appearance and she came in using a wheelchair.
Turns out the pulmonologist was blown away that the ER had dismissed her. She had a really rare small cell lung cancer. The reason the herpes infection manifested in the first place was her immune system was compromised. She told me the pulmonologist said I'd saved her life because they caught it early. It's been a bit over a year. She's still undergoing treatment but her spirits are strong and she's optimistic as is the pulmonologist.
Eye Doctor here. I had a patient I saw several months before they came in for their visit but well less than a year, which often means something could be wrong. In this case, as it turns out, nothing was wrong with her by way of complaints, she just wanted to get updated before getting some new glasses. We decided to just run the regular gamut of tests anyway just because we might as well while she was there. She was a 50YO woman, fairly normal exam, perfect vision, retinas showed healthy, but something about her pupils really bothered me before I dilated. We chatted about it and I asked her if she banged her head or anything weird and she said no, but suddenly reveals this crazy history of an old Meningioma (a type of tumorous brain growth) she had removed a few years ago. She had decided to omit this from her history with us as she didn't feel it was important, but we went and put it into the charts anyway. Turns out she got a CT done two weeks prior to her exam with me which she says turns up completely normal. I tell her she should tell her doctor about this anyway just to cover our bases.
Fast Forward: Patient shows up in my office ecstatic to tell me that my examination revealed that her tumor had returned with an incredible vengeance. She had no idea, was totally asymptomatic and the CT she had prior to me showed what was very literally the size of a spec of dust which the radiologist dismissed as "artifact". On her return to her doctor, they decided to re-run the CT to cover THEIR Bases, and they found a QUARTER SIZED TUMOR. Within Two Weeks the tumor went from the size of a dust particle to a QUARTER. She was rushed into emergency surgery as the tumor was growing SUPER fast and was close to a blood vessel which could cause a massive stroke. She had it removed that day and returned to me after recovery to tell me of what got discovered as a result of my testing. She is now a long time regular patient I have been seeing for about 10 years.
For those asking about the pupils, they were asymmetric, and the larger one reacted less robustly compared to the fellow eye. This was a marked change from her previous examinations where no pupillary defects were noted.
22 yo guy came in after seeing his primary at another hospital. His mom was my patient and asked if I would see him (I am an Internal Med doc). He had told his doctor he had a headache. I did a usual full review of symptoms since he was new and he also marked his left testicle had a lump. Did exam and he had hard small lump on testicle. Knew right away likely had metastatic testicular cancer. 1 stat brain scan and Testicular ultrasound later confirmed it.
Asked him if told other doctor about the lump and he said yes but the other doctor told him it was normal.
He lived, by the way, but it was close a few times. So fellows if you note a lump on your testicle ask for an ultrasound and don't be embarrassed to bring it up.
For those of you who are concerned after examining yourself:There is a small soft area posteriorly that should be similar on both your testicles known as the epididymis.That is normal. A hard lump on only one side only is not. Monthly self checks between ages 15-34 can be done but since rare (5/100,000) not a general recommendation.
Mid 30's man walks into my office with what looks like a black eye and a broken blood vessel in the front of his left eye. He went to his primary and it was simply assumed that he got punched or hit or something, and he was dismissed. He was noted to have high blood pressure, but a script for medicine was written and a follow up in a few months. Gentleman comes in to see me to get another opinion on the matter and I look at him and immediately start the line of questions: How long has it been there, do you have a headache, and when you plug your ears with your fingers do you hear a "wooshing" sound? He had a cavernous sinus fistula (CCF).
I sent him directly to the emergency room with his family of 4 in tow and he was in the OR within an hour of arriving. Saved his eye and possibly his life that day.
The best news: He was a kitchen guy at my local diner which I frequent and they still treat me like royalty there when I come to eat. They all remember the time I saved one of theirs.
Psychiatrist here. A 30 year old man with mild depressive symptoms was in-and-out of the hospital fairly quickly. He was under pressure from his home life, living with 4 roommates who were making life a bit difficult for him. No suicidal thoughts. He was cleared of all psychopathologies by me and two other doctors. A few months later he came back. Same symptoms, however this time he talked about 5 roommates. It felt wrong, and I digged in his story. Tried to contact his roommates. He lived alone and was severely psychotic. I have no idea to this day how he hid it so well from everyone.
EDIT: a few more details: The patient talked, dressed and acted normally however after admitting him for a longer period we noticed he talked with his "roommates" often. He was single, no contact with his family and somehow working, however in a routine job with little to no personal contact. After a few talks he also claimed other peoples thoughts were sometimes "thrown at him and sitting on his head", and he could thus read people's minds against his will. The interesting thing about this patient was, that his internal world somehow fitted the external world when asked - his roommates sounded perfectly plausible (they were not e.g. shadow-people, vikings, 12 m tall) and they teased him by hiding his stuff.
But he ate with them, watched TV with them, so on. Normally a person with paranoid schizophrenia (paranoid meaning all types of delusions) will have multiple symptoms sometimes easy to see for the untrained eye. The patients can dress, talk and present themselves in odd ways, usually different from cultural norms.
They can have incoherent speech, make up words and phrases or are clearly separated from reality (another patient of mine insisted that I was in jail for medicating him, even when we talked). When we quickly "scan" a patient for psychotic symptoms we basically look for inconsistencies in the patients experience of the world - the patients normally know "something is wrong" or "weird" or "different", but often belive it is the world around them, that have changed.
This is due to discrepancy between what they experience (input), failed assessment of the inputs (due to the thinking disorder) and testing hypothesis based on failed assessments which collide with the real world. This will activate defense mechanisms fx denial, wild explanations, accepting both "realities" at the same time, and so on. (e.g "I am not sick, my doctor must be a bad guy, bad guys are in jail, my doctor are in jail, but my doctor is sitting right in front of me at the same time, he must have an identical twin or this is an alternate reality). This is usually the way delusions are made.
To summarize: when we scan for psychosis, we look for inconsistencies between the patients subjective experience of thinking, being and acting and the objective reality accepted by the generel cultural norm. This patient managed to live in a subjective psychotic world that just fitted so well with the objective reality that he slipped by several psychiatrists including myself.
My grandmother had her hip replaced, but the hip always hurt to her. She waited a year, hoping it would go away but it never did, she asked multiple doctors and did multiple x-rays but doctors said the replaced hip was fine. We finally made her go to a private clinic in my hometown, and the doctor saw that the replaced hip was fine and dandy, but the bone around it looked like it was a tad bit eaten by bacteria.
So the new doc did an operation, and there was so much pus in the leg it was insane. If my grandmother waited any longer, her blood would become infected and she would have died.
Thank goodness she went to the clinic.
This is a 'I wish I had gotten a second opinion' story. I had a doctor in high school who was unconcerned when I suddenly developed vertical double vision (which was freaking out everyone in emergency, where I had gone initially) and lost 60lbs for no reason.
It was only a year or two later when I told him that my arm would fall asleep much faster than normal when I raised it to ask a question in class that he thought there might be something wrong with me.
MRI ordered. Brain tumour found.
At a clinic a lady came in for breast pain with a lump. I was in the room for the exam for safety of everyone. The doctor told her it was a sprained muscle and to go away. When he left the room I told her the name of one of our other doctors that specializes in women's health. Told her she could not let this go. She saw him and he referred her for some radiology and that's how they found her breast cancer. She later told us all this in a sweet card she sent telling us if I hadn't told her to advocate for herself she may not have followed up.
Dermatologist here. I have seen probably 5 instances of "My other doctor told me it was fine." that were melanomas. W
A lot of times people don't want a full skin exams. There are lots of perfectly sane reasons for this, time, perceived cost, history of personal trauma. However, I routinely find cancers people don't know they have. Keep this in mind if you see a dermatologist for acne and they recommend you get in a gown.